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General NPI Number Information
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NPI Number | 1528208758
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Entity Type | Organization
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Legal Business Name | MIRAGE MEDICAL GROUP
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Dates
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Enumeration Date | 02/27/2009
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Last Update Date | 02/27/2009
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Provider Practice Location Address
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Address Line | 69844 HIGHWAY 111 STE K ONE HAWKEYE PARK
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City | RANCHO MIRAGE
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State | CA
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Zip | 92270-2849
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Country | US
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Telephone | 760-770-4166
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Fax |
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Provider Business Mailing Address
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Address Line | 44650 VILLAGE CT STE 100
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City | PALM DESERT
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State | CA
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Zip | 92260-3812
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Country | US
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Telephone | 760-346-4003
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | MR. ZORAN RUBAKOVICH
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Credential |
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Telephone | 760-346-4003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | A51307
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License Number State | CA
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